Is feeling “good”, good enough? Or could there be a next level of performance and health awaiting you? This is a guest post from Dr. Cate Shanahan, one of the world’s leading primal/paleo-aligned MDs, noted author and speaker on ancestral health principles, and family practice physician in Napa, CA. Cate also designed and now serves as medical director of the Los Angeles Lakers cutting edge PRO-Nutrition program. She co-authored (with her writer husband Luke Shanahan) the grass roots sensation Deep Nutrition – Why Your Genes Need Traditional Food, and followed it up with the excellent practical shopping and food preparation guidebook, Food Rules.

Dr. Cate’s unique approach to wellness is centered upon a nutrient-intense eating strategy she calls “The Four Pillars of World Cuisine”. Cate blends her formal medical training and scientific research (in biochemistry and genetics at Cornell) with insights she learned practicing medicine and studying ethnobotany at the National Tropical Botanical Garden on the island of Kauai. In particular, she noticed the exceptional health and work capacity of the population she served in rural Kauai, who ate a superior diet of pasture raised animals and locally grown produce, and lived a low stress lifestyle.

Cate and Luke will join us at PrimalCon Vacation Tulum, where Cate will deliver a keynote lecture on the Four Pillars and Luke will conduct an intensive workshop for aspiring writers.

I’ve been a fan of Mark Sisson for a long time but I first became associated with Primal Blueprint Publishing through Managing Editor Brad Kearns several months ago. In discussing my medical practice and my Four Pillars strategy to optimize dietary habits, Brad mentioned to me that he had some strange adverse findings on his blood tests. By all accounts, Brad would be considered a healthy, athletic, and Primal-aligned guy – he was a national champion and #3 world-ranked pro triathlete back in the 90s, coached by Mark Sisson!; today at age 48 he participates in high jump, sprinting, and basketball.

With the ancestral health movement in full swing, the CrossFit Games selling out large stadiums and being nationally televised, there is a growing population of folks who are super fit, eat a nutrient-dense, Primal/paleo style diet, but may be unknowingly falling short of peak performance and optimal health. When Luke and I approached the Los Angeles Lakers, this was essentially our pitch to the team training staff – that they had some of the most magnificent and finely-tuned physical specimens in the world on their squad, but that the team, and each individual player, were quite likely missing opportunities for optimal performance and recovery in their diets.

Everyone involved in professional sports – coaches, athletes, trainers – will tell you that recovery is everything at the elite level. While Kobe Bryant has done some amazing things on the court over 1,200 games and 17 seasons, his equally amazing off court discipline keeps him in the game – his intensive workout regimen, and the hours devoted to rehab and recovery practices each day are what enable him to maintain the highest level of play for years and years.

This article is directed to those of you who may be doing things really well overall, performing in a manner that the “average” person would marvel at, but may still be unknowingly falling short of your potential. You may not have any adverse blood findings laying around, but you can certainly ask yourself some important questions: Are you stalled with weight loss progress? Do you have energy level swings relating to workouts, or meals? (One important marker for my athletic patients is to determine if they get hungry a few hours after eating, something that can indicate your metabolism may not be nimble enough to provide you with the energy you need). Do you have any difficulty getting to sleep, staying asleep, or waking up refreshed and energized? Even if things are great, could they possibly be even better?

While Brad’s blood panels showed some awesome numbers after five years of Primal eating and exercise (a triglyceride-to-HDL ratio that was even better than the optimal goal of 1:1; and triple the testosterone he had from age 26 when he was mired in an extreme endurance training regimen), he also revealed some significantly below normal range values for assorted white blood cell values (white blood cells, neutrophils, fibrinogen), as well as elevated fasting glucose (strange for an extremely Primal-aligned/cyclic ketogenic eater).

These lab abnormalities are, to me, red flags. Unfortunately they usually do not draw the attention I believe they deserve. Possibly because they are so common, many docs have gone numb to the possibility that they could mean anything. Or, they may be misattributed to genetics. It doesn’t help that physicians, dietitians and other professionals – at least those who rely solely on their formal training – remain under-educated in the fields of nutrition and metabolism. When I track down old reports of previously done labs on my new patients, the paper trail often shows they’ve had these kinds of warning signs for years.

A doctor lacking nutritional/metabolic expertise is not a criticism – it’s simply not part of their formal training. You could just as easily assume they know nothing about sailing or skydiving. When I started my medical practice, I didn’t have a clue about nutrition or metabolism either. The only reason I have a clue now is thanks to time spent – about five years – updating my education, accomplished by reading a small library’s worth of textbooks and articles from Medline and attending medical meetings held by relatively enlightened societies like the American Academy of Bariatric Physicians and the Nutrition and Metabolism Society. Much of what I learned is now compiled into the two books I’ve co-authored with my husband Luke.

Lab findings like those Brad delivered are likely due to a significant mismatch between nutrition input and metabolic output and I take them seriously because they are powerful gauges of metabolic health. The bone marrow must pump out enough white blood cells to keep our counts between 4,000 and 11,000 WBC per millimeter of blood, and it takes 20-plus hormones to regulate blood sugar. The inability of a person’s diet to keep up with the demands of these two very active metabolic enterprises usually does not lead to significant health problems – until a person experiences major stress.

I have learned that these two tests and a handful of others that I use act like metabolic crumple zones where the pressure of a persons daily routines impact upon a less-than-optimal diet (i.e. not inclusive of all Four Pillars) with visible consequences. Like a car deliberately engineered to collapse at certain points to best protect the driver during an accident, these metabolic crumple zones take the hit first when your metabolism is beginning to crash. This metabolic engineering works so well that you may not feel anything wrong – if you don’t push yourself that hard. But commonly, as in Brad’s case, a bout of athletic competition and peak performance, high-energy output is followed by troughs of low energy, fatigue and even the occasional “burnout headache” as Brad described.

Fortunately, the health consequences that arise from metabolic imbalances related to voluntary, athletic outputs that demand more nutrition than the body inputs tend to be short lived. What was likely contributing to Brad’s burnout experience were muscle catabolism (breaking down muscle) and inability to hold on to electrolytes like calcium in the aftermath of his super high intensity workouts of strength training. While Brad’s reported dietary intake was your basic Primal A+ diet (carb conscious, lots of top quality – and not overcooked – grassfed beef and pastured eggs; abundant servings of fresh produce; snacks like macadamia nuts and dark chocolate, and an absence of nutrient depleting foods) I realized, like some other hard-core athletes I treat, that he was pushing his body to the point where he needed not just a great diet, but an optimized one. This is where the Four Pillars come in.

The Four Pillars of World Cuisine detailed in Deep Nutrition represent how successful cultures use the same four strategies to optimize the nutrition they could extract from their surroundings. They are:

Fresh

Fermented and sprouted

Meat on the bone

Organ meats

Each of these categories of foods offer a variety of unique benefits, but to give you a taste I’ll share one example from all four categories. Fresh foods are the best sources of antioxidants. Fermented foods offer probiotics. Meat on the bone offers glycosaminoglycans, which trigger collagen development in joints. And organ meats are such intense sources of nutrition they make many other so-called super foods pale by comparison.

Our ancestors’ survival depended, ultimately, on their personal health and vitality. People like to talk about how our lives are so stressful these days. While they’re undoubtedly correct, life has always been stressful. Your village would get invaded, your cousin would get eaten by an alligator, you’d deal with droughts/floods/mosquito born illness, epic battles and on and on. But our primal ancestors managed to survive in spite of all that largely because of the way they ate. And according to the best available evidence from modern science, cultures around the globe included foods from all Four Pillars.

Flash forward to a person today with low WBC (or any of the other subtle abnormalities that typically get ignored) due to the dietary input-metabolic output mismatch – something I see particularly often in adults in their 30-50s and even in those who consider themselves pretty healthy (i.e., paleo-style) eaters. How will he or she handle serious stresses? Even with one or more important metabolic indicators out of alignment, people can go about their business, exercise, work, and keep up with their kids until… something really bad happens. And then, something else really bad happens. And something else. If the stress is unrelenting then, in the aftermath when things finally calm down and the body’s cortisol levels plummet, the consequences upon a person’s health can get pretty devastating.

Life is still is as unpredictable today as it always has been, so we still would benefit from fortifying our bodies pro-actively like our ancestors did. But we don’t. Our culture is re-active, not proactive. Most people wait until something happens to consider making a change. We don’t value optimal nutrition and so have largely forgotten what it even looks like.

I believe that’s why, just about every day, I hear a story of an unbelievable sequence of bad-luck events that are soon followed by life changing health problems. Yesterday’s came from a woman in her fifties who got divorced, then her best friend got cancer, then her son got married to someone she doesn’t get along with, her mother had to go into a nursing home, and somewhere in there she fell off a curb, fractured her ankle and lost her job temporarily – all this in one year. Two years ago, she was fine. Now she’s in my office with a painful and fatiguing auto-immune syndrome that specialists from the Mayo clinic are treating with several powerful immune system suppressing medications, and in spite of those meds just getting dressed in the morning is a painful exercise.

Would this have happened to her if someone had noticed those metabolic crumple zones beginning to wrinkle and optimized her diet? No one can say for sure. But in my view, the odds that significant stress will lead to life-changing health repercussions are greatly increased by ignoring the warning signs and failing to fortify your diet with the same foods are ancestors ate.

Of course, some people have the genetic good fortune to handle stress (not to mention perform physically) better than others. Take world-class athletes who stress their bodies to the limit on a daily basis. They don’t often get outright sick, but they might not have the energy they want game after game, or have the extra energy to play with their kids after workouts. Many turn to sugary blasts of candy or soda on a regular basis, not realizing that they’ve entered a Faustian contract with their metabolism. Before they realize it, this one wrong turn – making a regular habit of sugary treats – has led to metabolic changes that can make the difference between playing another 3-5 years, or finding themselves replaced by a younger, fresher athlete.

But not for players with the Los Angeles Lakers. Thanks to head trainer Gary Vitti’s, the Lakers take a proactive approach to health optimization and in 2012 Vitti invited Luke and I to join a team that includes head strength and conditioning coach Dr. Timothy DiFrancesco and Chef Sandra Padilla. Our coordinated efforts are bringing Deep Nutrition to the Lakers, and those players who are able to make changes have noticed dramatic improvements in their energy levels.

The Lakers had some troubles with injuries last year, so our PRO Nutrition (Performance Recovery Orthogenesis) team can’t brag about any titles just yet. But just wait until Kobe comes back from his Achilles tear stronger than ever! I should also mention Steve Blake and his wife Kristen, who really embraced healthy eating with full intensity. At the beginning of the 2012-13 season, Steve struggled with injuries that kept him on the bench. By the end of the season, he was performing at a career best level (making 42% of his three-pointers) such that they were calling him the White Mamba!

In Brad’s case, he had been almost entirely missing out on two of our Four Pillars. So I recommended he start adding them in by upping his intake of mineral- and glycosaminoglycan-rich bone broths and nutrient intense liver from pastured animals. I made a few other recommendations and less than a month later, after years of being low, his WBC have finally normalized. Normalizing glucose can take longer, and can take dedication to staying on the Four Pillar path. But in my experience, it’s a road well worth traveling.

You want comments? We got comments:

Imagine you’re George Clooney. Take a moment to admire your grooming and wit. Okay, now imagine someone walks up to you and asks, “What’s your name?” You say, “I’m George Clooney.” Or maybe you say, “I’m the Clooninator!” You don’t say “I’m George of George Clooney Sells Movies Blog” and you certainly don’t say, “I’m Clooney Weight Loss Plan”. So while spam is technically meat, it ain’t anywhere near Primal. Please nickname yourself something your friends would call you.

You can’t just be awesome, great, or even the best. You have to be super-human!

This article makes me think of Michael Phelps and his ridiculous eating habits that fill him up with the thousands of calories his body needs. It’s all pizza and pastries and energy drinks and pasta and other crap. I’m sure genetics has played a huge role in his performance and ability to get by on eating whatever.

I can’t help but imagine how his performance would have been had he ate meat, seafood, organs, starches, fruits, nuts, fermented dairy, and honey…

Good question. Swimming seems like a different beast than most sports because the body is burning more energy to stay warm in addition to the physical exercise; where most other sports the body is trying to cool down.

Not if you modify it to include larger amount of calories and carbohydrates? Please explain, because modified-macro-nutrient ratios and increased carb-intake still fit pretty well with the paleo label.

Fantastic article. Catherine Shanahan’s book was an eye-opener; changed my and my family’s eating habits to incorporate more bone broth and fermented foods. It all just takes a little effort to adjust to preparing these on top of your other food preparation jobs – and sacrificing a bit of telly!

Will be interesting to observe how my kids grow and develop over the coming years – that’s the most important thing in the world to me :: avoiding/lessening the health issues I’ve suffered from in my life!

I am very glad I read Deep Nutrition some time ago. It’s definitely one of those must read, life altering books. It’s also an original work. Today you can buy a ton of different Paleo books and although the better authors add value they all mostly say the same things. Deep Nutrition provides different and unique information.

Organ meats are where it’s at. Notice that when carnivores make a kill, they preferentially eat the nutrient-rich organs, leaving the muscles to the scavengers. Modern society has reversed that – the “alphas” eat expensive prime rib, leaving the organs to languish, cheap, in the back of the display case.

Take advantage of this inefficiency. The simplest meal in the world is chopped onion, leafy greens and chicken livers quickly sauteed in coconut oil. This is one of the few meals I eat that leaves me feeling noticeably sharper, stronger and happier for the whole following day…

This is interesting! I have never looked at nutrition like that. I have been able to do amazing things for people by looking at allergy’s to certain foods like gluten or dairy and just structuring a solid diet. This takes it to a whole new level!

I am curious to see what cooked liver tastes like. Are there any good ways of cooking it?

William, I just made some grassfed beef liver yesterday. Here’s my method:

soak it in some form of dairy (milk, yogurt, buttermilk, etc) or acidic water (vinegar, lemon juice) for a hour/day beforehand. this helps decrease the ‘iron’ taste many people find objectionable. If you want to go further, you could lacto-ferment it a bit.

when you’re ready, drain it, pat it dry, and heat your lard in a big skillet to very hot (you cook with lard, right? you could also use bacon grease or even coconut oil, I guess). place the liver (it usually comes pre-sliced) in the oil and fry for thirty seconds, flip, and fry for fifteen-twenty seconds. Do not overcook. Remove to a plate, continue with remaining liver slices.

by this time, there will be brown stuff stuck to the pan. pour a 1/4 cup of wine, beer, orange juice, whatever, and scrape the pan clean. let the liquid come to a boil ( i add heavy cream at this point) and thicken. salt and pepper to taste. there’s your gravy. pour over liver and eat that stuff up.

Chicken, beef or pork (or something else)? If you’ve never had liver before, the flavor is fairly strong. You can ease into it by making meatballs, burgers, or meatloaf with beef liver incorporated into the ground beef. Pate and liverwurst are also great sources of liver – just make sure you read the labels since many commercial brands are filled with sugar. Chicken livers are pretty tasty fried with a light layer of flour – I use a mixture of rice and tapioca flour which are pretty low on the anti-nutrient radar and the amount used is minimal in terms of carbs. For recipes, search “primal liver meatballs” or something similar.

@ William
I just used the search on this site that brought up a recipe for Pork, Beef and Liver Terrine. Looks/sounds good. I’m going to try it out and see if I can make it for lunches for the school year.

The vessel used to cook the force meat mixture is the only difference between a pate and a terrine. A terrine can only be called a terrine if a terrine dish is used; any other non-terrine vessel used to cook in a bain-marie (a water bath) is a pate.

So do not let a cooking vessel limit your searches. Pates are awesome too. (Yes, I am half French, am proud of France’s culinary accomplishments, and a stickler for certain traditions and definitions).

I’m half Americanized French Canadian. My grandmother didn’t cook (really!), although she did work as a cafeteria lady in the 70’s and early 80’s. I can actually trace my French ancestry to the people who stepped off the boat, thanks to that same grandmother.

And I say don’t take the French too seriously. The food is wonderful because they are stickler for details, but worrying about the difference between a terrine and pate springs entirely out of the French view point of the world. (At least that’s what my English half and 1/64 Native North American tells me.) It’s all just liverwurst with fancy names. *grin* (And sometimes mold it in Jell-O for good measure.)

I always wondered why so many French recipes calling for cooking at low temperatures instructed me to go take a bath with Marie while the food was cooking. I’ve since learned what a bain-Marie is in culinary terms, but my recipes are now way less fun.

Mantonat wrote on August 15th, 2013

Stress always comes up. I think it’s the biggie. I try to navigate most of my life around NOT being stressed. When the shit hits the fan (death, injury, illness, finances hit, etc.), I go from 90% Primal to 100%. I got thru my fathers death in pretty good shape. I believe stress to be the #1 killer. We live in a crazy world and it feels good that I pretty much got off the merry-go-round. Still no cell phone for me…and loving it!

Guess I won’t pass on that pastured liver at the next farmer’s market! I should also step up my bone broth game, although this would require me purchasing more quality meats (it hasn’t been in the budget recently, but I see that changing very soon). I’ll also need to get a copy of Deep Nutrition…I love the sound of it and as a former collegiate athlete and current recreational athlete, I want to know more.

On another note…couldn’t it be any other team besides the Lakers?! I kid. Kind of.

Bones sometimes can be purchased cheapily. Buy whole chickens and learn to break down the bird yourself. Get the chicken feet. Save the bones if you ever make osso buco or other cuts that have a bone in. Bones can be reused to make a second stock, this is called a “remouillage”, or a “remi” for short. Bones freeze well too. After the second go around in the stock pot the bones are spent, throw them out or feed them to a dog.

True. I can get fish racks from my local fish monger, but not bones from my butcher. My local butchers roast their bones to sell as high end dog treats. Kudos to their entrepreneurship! Sadly I am left to compete against the dogs.

I don’t know about those in America, but over here in the UK liver is eaten quite often, it’s an acquired taste admittedly, those who like it love it and those who dislike it, hate it! I’m firmly in the love camp now, despite hating it as a kid. it’s traditional in the UK to have it with bacon and onion gravy, usually over mashed potato and cabbage.

I agree. If the Lakers win another title, it wont come as a big surprise. It would be interesting to see what advances could be accomplished with a perinnial “back of the pack” team, like the Charlotte Bobcats. (I hope I am not offending any Bobcat fans)

This is my question also. I just LOVE chicken livers, especially as an accompaniment to my morning omelet. However, I have not found a reliable source of pastured livers. I still eat the ones I get at the grocery, just because I love them so much, but I wonder if I am doing more harm than good from a nutrition point of view.

Interesting post. The bit about “metabolic crumple zones” and “sequence of bad-luck events that are soon followed by life changing health problems” explains perfectly why my husband developed some chronic mystery illness(es) after an out-patient procedure 2 years ago. Nobody seems to know what is going on, and I am sure that if he would eat at least close to primally, he’d feel much better.

Isn’t elevated fasting blood sugar a bit common among the Paleo/Primal folks? (See Chris Kresser’s website). It’s called the Dawn Phenomenon and isn’t considered pathological in any way (just like the physiological insulin resistance that will come with very low carb diets). Post-pranadial response, IMO, tells you more about your blood sugars than Hba1c or fasting. (Like mine. I had some sweet chinese food – 2 hours after eating: 146mg/dl; 3 hours: 144mg/dl. – I have seen worse numbers than this, too) I have normal fasting blood sugars. My hba1c is around 5.0. I am pre-diabetic.

I have a crappy Phase I response and even my Phase II response can’t take care of that much sugar (I don’t eat the rice and the sauce was definitely made with corn syrup) at one time. Yet my genetics puts me at around 3% below the general population

Me too… I actually love chicken livers but they look & feel so very… er… unpleasant… when raw. Still I try to cook them once a week because I can feel their positive effect on my system right away. My prefered method is broiling because it’s super-simple, but a good pate or chopped liver is yummy. When I first started cooking them I would wear surgical gloves when prepping to minimize squeamishness, but I can handle it now. I’m an ex-vegetarian, btw. Also ex-anemic!

Must admit I never thought of them *that* way, although they do seem strangely almost alive & wriggling… in a very disconcerting way. I’m not sure your point of view would help me slice & broil them! Though I would be even more squeamish about eating them raw…

I once ate a live shrimp at a sushi bar– feeling very adventurous (& to be honest, quite tipsy) at the time– was told it was a great delicacy– but it *seriously* freaked me out once it was in my mouth!

Dr Cate, I have a question regarding blood sugars. I suffer from terrible hyperinsulinemia, and a couple of hours after even eating a small amount of leafy green vegetables I am suffering from symptoms of low blood sugar. I tend to feel best on an almost zero carbohydrate diet, to not give my body any excuse to release insulin. I know that this is not particularly healthy as I am missing out on so many nutrients by limiting vegetables. Do you think that by following your four pillars of nutrition, I could potentially ‘fix’ my blood sugar and insulin problem?

Folks – I’ve grown from a picky eater as a child to a more adventurous one as an adult, and a primal one in the last year or so. But I still hate the thought of organ meats. Any ideas on the best way to introduce them to start liking them at best, or not realise that they are really there?

I teach classes for parents of picky eaters (or who are picky eaters themselves!) and here are a few of the suggested methods to encourage someone to try and ultimately eat a food they do not like:
1. Continue to offer it. Kids take approx. 12 tastes (over a number of years) before they may accept a new food. Adults- less tastes necessary.
2. Use a sauce or dip to mask flavor- sometimes someone is extremely sensitive to a flavor and will never get used to it.
3. Offer it BEFORE the meal presented as a tasty appetizer when the person is hungriest.
4. If all else fails, hide it in another food. I make meatloaf that is 1/3 beef, 1/3 pork, 1/3 liver, with lots of veggies & seasonings, and my liver-hating family has no idea!
Hope that helps!

Ben, get yourself some really fancy chicken liver pate. No duck liver, just chicken – it’s milder. Try one flavoured with oranges (slightly sweet), or better yet, herbs and fortified wine or brandy (amazing). Get it from a deli or fancy grocer, not the cheap supermarket stuff. (Also, better chances of getting pate made with butter and cream, not vegetable fats that way.)

I’m from the UK too, and have eaten offal since I was a child. I eat liver once a week, pig, lamb or beef, I slice it wafer thin while still slightly frozen and fry it in a couple of minutes in butter with some chopped sage, sometimes adding kidneys too as they cook in a similar amount of time, or fry up the kidneys separately first and then add a tomato based or creamy sauce. Hearts I do in the slow cooker, in a variety of sauces, to me the texture is then of a very firm beef steak. I’m lucky enough that my two suppliers of grass fed meat just throw in the offal for free as no-one wants it!

I found something on Kauai that helps me cope with mental stress, a CD of slack key guitar music by Kauai native Paul Togioka. It’s titled Ki ho’alu Inn. The music goes right to my bones and no matter what the circumstances, by the second or third song I’ve mellowed out and life is looking up again.

It is fantastic that this way of eating is finally being recognized and implemented in the professional sports arena. Once we see the benefits it has for these athletes, I think this will go along way in bringing even more attention to it in the general public and media.

Great work Dr. Cate. Too bad you don’t run a family practice in Vancouver Canada. Do you have any Dr suggestions for us who live up here in Vancouver?

I find the elevated fasting glucose levels interesting in the Paleo population. It does not seem glucose should be elevated with a low carb/ketogenic approach to diet and lifestyle. Insulin should be working more effectively? Can anyone explain this more??

This was an excellent post! I’ve recently included more of all those foods in my diet, and I noticed a big difference with the bone broth. My nails started to get a slight sheen to them on their own and, when I was drinking multiple cups a day, my perpetually chapped lips started to heal. Granted, I play the clarinet, and that stupid reed doesn’t just dry lips out, it literally steals their life force, so I’m sure if I stopped playing, my lips would be better off, but some things aren’t optional.

There’s a restaurant down the street that serves the most amazing chicken livers. They’re not breaded or anything, just sauteed in a maple sherry glaze and topped with scallions. OMGZ, they’re an appetizer and I go there just for them. Once, they had a special appetizer — roasted bone marrow. That’s when I discovered that bone marrow isn’t creepy, it’s delicious!

I think liver is disgusting but I eat it twice a week cause its so healthy. I know this sounds gross but I promise you this is the best way to eat it. I can barely taste the liver. I eat it raw blended in a shake with vanilla protein and cinnamon. Don’t be shy with the cinnamon. It really covers up the taste. I use Whey Natural USA protein which is undenatured and comes from grass fed cows. This is my post workout shake twice a week. I use four ounces of liver.

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